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MEDICAL PRACTICE UNDER THE INSURANCE ACT.
1148 transferred to
Darjeeling and appointed to officiate as Civil year. With previous service he became Surgeon-Lieutenant Surgeon during the absence on sick leave of Major J. in 1893 and attained the rank of Major in 1905. He served Gwyther. Major H. B. Foster has taken up duty at in the South African war and took part in the operations in Calcutta. Major N. P. O’Gorman Lalor has arrived home on the Transvaal and in the Orange River Colony 1901-02 leave of absence from India. Major J. 0. Robertson has (Queen’s medal and two clasps). He was specialist in been appointed Sanitary Commissioner at Delhi. Major dermatology at Cairo in 1904, at Woolwich in 1905-06, and J. H. McDonald has been granted six months’ extension of at Malta in 1909. leave of absence home from India on medical certificate. Major L. J. M. Deas, Agency Surgeon to the Bhopawar State, has been appointed to officiate as Political Agent during the absence on leave of Lieutenant-Colonel B. E. M. Gurdon, C.I.E., D.S.O. Major V. H. Roberts, Civil Surgeon at Seoni, has been appointed to hold medical charge of the Chhindwara District during the absence of Captain W. J. Fraser on special duty at the Central Research Institute, Kasauli Cantonment. Major W. F. Harvey has taken up duty as Director of the Central Research Institute at Kasauli Cantonment in succession to Sir David Semple, R.A.M.C., who has relinquished the appointment. Captain N. M. Wilson, on return to India from leave of absence home, has been appointed to officiate as Civil Surgeon at Dera Ghazi Khan. Captain R. H. Bott has been appointed to officiate as Professor of Surgery at the Government Medical College, Lahore, during the absence on leave of Lieutenant-Colonel E. V. Hugo. Captain A. S. M. Peebles, superintendent of the Central Lunatic Asylum at Berhampore, has been appointed to officiate as Civil Surgeon of Murshidabad during the absence on deputation of Major C. A. Lane. The services of Captain R. S. Kennedy have been replaced at the disposal of the Government of India. Captain A. C. Ingram has been granted leave of absence home from India for one year and eight months. Captain M. J. Quirke has been appointed to officiate as Sanitary Commissioner to the Madras Presidency during the leave of absence of Captain M. A. Justice. Captain G. A. Jolly has been transferred fram Mainpuri and appointed Civil Surgeon at Fategarh. Captain H. S. Hutchison has been appointed to officiate as Deputy Sanitary Commissioner of the Central Registration District in Bombay during the absence on special duty of Lieutenant-Colonel T. E. Dyson. Captain J. H. Horton, D.S.O., has been appointed Civil Surgeon at Sukkur during the absence on leave of Major C. R. Bakhle.
SPECIAL RESERVE
OF
OFFICERS.
George F. Randall to be Captain (dated Sept. 19th, 1913). Lieutenant Charles J. Simpson resigns his commission (dated Oct. 15th, 1913). Lieutenant Henry P. Crow is confirmed in his rank. Lieutenant
TERRITORIAL FORCE.
Royal Army Medical Corps. lst Welsh Field Ambulance, Royal Army Medical Lieutenant Edmund V. Connellanto be Captain (dated
Corps : August
1st, 1913). 2nd Welsh Field Ambulance, Royal Army Medical Corps : Lieutenant John S. Rowlands resigns his commission (dated October llth, 1913). Attached to Units other than Medical Units.-Lieutenant Lewis Beesly to be Captain (dated June lst, 1913). Lieutenant-Colonel William Wilson resigns his commission, and is granted permission to retain his rank and to wear the prescribed uniform (dated October llth, 1913). For attaohment to Units other than Medical Units.Sidney Scott (late Second Lieutenant, 4th Northumbrian (County of Durham) (Howitzer) Brigade, Royal Field Artillery), to be Lieutenant (dated October llth, 1913). DEATHS
IN THE
SERVICES.
MEDICAL PRACTICE UNDER THE INSURANCE ACT. (BY
SPECIAL
COMMISSIONER.)
(Continued from p. 1024.) XXIII.—NEWCASTLE : EARLY ORGANISATION UNIONS AND THEIR DECAY.
OF
MEDICAL
AT Newcastle I found much dissatisfaction still prevalent to the manner in which the resistance to the National Insurance Act had been conducted, and in regard to the attempts to amend the Insurance Act the same feeling was expressed. It must be borne in mind that both in as
Northumberland and Durham the medical profession has been organised for some time, so that failure was not expected. Many strikes have taken place, and on the whole the medical unions in these contests came off victorious. Since the autumn of 1900 the work of organisation had been particularly active, and, indeed, I have described at length some of the achievements of the Northumberland and Newcastle Medical Association, and other bodies like the Newcastle Medical Ethical Society and the Northumberland and Durham Medical Union.I One of the chief of these achievements was the raising in most of the colliery districts of the sums paid to the colliery surgeons by no less than 50 per cent. Formerly the collier paid 6d. a fortnight for medical attendance on himself and his family, and this was raised to 9d. Then the war against imported medical men proved very effective, a black list was rigorously kept, and the cooperation of consultants was obtained. The different bodies, some of whom afterwards coalesced, were well disciplined fighting bodies, and their union was not merely a name but a reality, for they fought and won many a battle. To-day, however, what remains of these organisations has lost much of its old vigour with loss of individuality. This, perhaps, was inevitable. The British Medical Association, which under its new constitution absorbed these Northern medical leagues, was expected to strengthen the influence of the local unions, while it was said that expense would b& saved for those members who belonged to their local union It was aareedas well as to the British Medical Association. that the organisation of the unions should be maintained under the name of a committee, the Durham Committee and the Newcastle Committee of the British Medical Association. This amalgamation was effected some three years before theNational Insurance Bill was discussed, and did not work harmoniously. Nothing will be gained now by raking up old grievances ; it suffices to say that at one timethere were acute differences of opinion in Newcastle on the subject of united action in regard to the National Insurance Bill, but when the offer of 8s. 6d. was made public it was soon quite clear that resistance would no longer be possible. Professor Rutherford Morison and many others still think it would have been wiser to have accepted under protest this offer instead of exhibiting the weakness of the organisation of the profession by an abortive attempt at resistance. Nearly all the general practitioners went on the panel. The Insurance Oommi!tee’s Work. The population of Newcastle is 266,603, according to thelast Census, and the Insurance Committee has the record of 87,000 insured persons. There are 110 practitioners on the panel, though a few of them are not actually residing in Newcastle, but practise in the suburbs. The panel doctors were promptly paid on April 15th, the very day the money was due, the full Is. 9d. per person insured for their first quarter’s
Lieutenant-Colonel John Ritchie, R.A.M.C., on Oct. 6th Glasgow in his fifty-second year. He entered the service 1887, and in 1898 went out to West Africa. He was present at the operations in Sierra Leone, 1898-9 (medal with clasp), and during the South African war took part in the operations in the Orange River Free State in 1900, and later in the operations in the Transvaal, including the actions He was near Johannesburg, Pretoria, and Diamond Hill. also engaged in the operations in the Orange River Colony, including the actions at Wittebergen, and in Cape Colony, south of Orange River (Queen’s medal with four clasps and the King’s medal with two clasps). 1 See THE LANCET Major Herbert Cumming French, R.A.M.C., in his 44th 22nd, 1902. in in
OUR
of Feb. 23rd and April 6th, 1901, and Nov. 15th and
1149 work. The same business-like regularity occurred again on good feature already manifest in the attitude of the people -July lst, 1913. There remains a very large number, more at Newcastle. The idea of early treatment is becoming than 8000, of insured persons who have not yet selected a more and more popular. Also confidence has grown as to medical attendant. The money that these persons have the discretion observed at the dispensary. Nothing is ever .paid was divided equally among all the panel doctors. But said except in regard to children attending school, so that it is now proposed to allocate these insured persons, giving a adults coming for advice are not afraid of losing their larger number to the panel doctors who have the shortest employment. Thus persons who are in doubt now come ’lists. One panel doctor has about 3500 names on his freely to be examined at the tuberculosis dispensary, and list, and there are a few who have over 2000, but therefore it is all the more necessary that proper premises The great majority of panel doctors should be secured. this is exceptional. The are responsible for less than 2000 insured persons. Where the Wage Limit is Needed. .clerk of the Insurance Committee thinks that the Act In Newcastle the panel doctors working in the industrial is working well, and the fact that there has been no meeting of the medical subcommittee to sit and judge whether com- districts are well satifRed with results. In neighbourhoods plaints made as to medical attendance are well founded or such as Heaton they can get their visiting done with ease not is in itself evidence to the same effect. The dispensing and promptitude owing to the fact that the ceremonies of .chemists have been paid 85 per cent. on their claims. Their social calling are not required of them. But in the West-end bills have exceeded the Is. 6d., but when the floating 6d. is the position is different. Here we have a population of .added they have not overstepped the 2s. During the better clerks and persons of moderate incomes who are employed In the in trade or commerce. They live in small, well-kept, selfreason of the year the small deficit may be met. .meanwhile, it is very certain that more medicine has been contained houses, and many keep a servant. When the panel
.consumed than was ever the case before. If, therefore, are of real service, the inhabitants of Newcastle should now be in the enjoyment of better health than formerly. Of - course, some allowance must be made for the presence of malingering, of which complaint is made here as elsewhere. A scheme is being considered to create a medical committee whose business it should be to investigate suspected cases of malingering, and the proposal is that the panel doctors should sit in rotation on this committee, so as not to deal with their own cases. But, on the other hand, the objection .can be made that the detection of malingering is a specialty in itself, and every doctor is not equally competent. The fact recently announced that the Government is now attending to the matter has, however, checked to some extent local .efforts. Already two new committees are to be brought into existence in accordance with the recent amendments to the Act, one to represent exclusively the panel doctors and the other the dispensing chemists. As yet I have heard no complaints against this procedure. As long as the general Medical ’Committee representing all the members of the profession in the area remains intact, there seems to be no objection to the formation of minor committees to attend to special matter concerning individually the members of such committees and those who nominate them. However, these supplementary committees are not necessarily to be formed at once, so it is somewhat early to criticise.
doctor calls he cannot open the street door, announce himself, and walk straight in. He must ring the bell, wait perhaps while the servant girl puts on a clean apron before she opens the door. Then instead of seeing the patient at once he is introduced into a small parlour, where he lingers till the patient is apprised of the visit and has had his bedclothes straightened out a little. Altogether, the doctor finds that the visits to his contract patients absorb as much of his professional time as those to his private patients. This class of patient has been accustomed to pay the fees-low fees, of course-to their medical attendants; and the fact that to-day they are insured persons makes no difference to their domestic arrangements. Their front doors remain shut, and the doctor, whether on the panel or not, must ring the bell to gain admittance. Among the colliers living side by side in a row of little cottages, with their front doors open, it would be possible, though not desirable as a routine, to make 20, even 25, visits in an hour. At Newcastle, in such districts as Heaton, perhaps 15 visits may be made in the hour, but in the West-end three, four, Yet or five visits is the most that can be done in that time. in all these cases the remuneration under the contract system is exactly the same. So enormous is the difference and the loss it entails on the West-end practitioners that three of them have resigned their position on the panel. Here more than in any locality which I have yet visited has the necessity for establishing a wage limit seemed clearest to me. It is said, Inadequate Tuberculosis Dispensary;. however, that it is not worth while taking the great amount By far the most urgent matter at Newcastle at the present of trouble this would entail, for there are so very few insured moment is to obtain suitable premises for the tuberculosis persons whose income is above .6104 a year and under .6160. dispensary. This institution is for the moment situated close That is doubless true ; but if their number be small in comto the town hall. It is very accessible, but the street is so parison with a total of some 14,000,000 insured persons, noisy that it is difficult to examine the patients. Then the they cluster together, and in certain districts they dispensary only consists of two small rooms or compart- constitute perhaps the large majority of the inhabitants. One of these is the clerk’s room, the store-room, the Thus, if the medical profession as a whole does not suffer ments. writing-room, and the waiting-room, all in one. The other is much for the want of a wage limit its absence means grave the consulting-room, the bacteriological laboratory, and the loss for individual practitioners living in the districts where patients’ dressing-room, also all in one. An enormous this class of insured persons habitually resides. One practitioner in the West-end, who had about 1200 amount of time is lost by the medical officer, who has to wait till one patient has resumed his clothes before another insured persons on his list, told me that his private practice patient can be admitted into the room. But it appears that among people whose income exceeded Z160 amounted to when efforts have been made to rent larger and more 30 per cent. of the whole practice. The remaining 80 per suitable premises the people living near have raised objec- 3ent. were all insured persons, and of these only 32 per cent. tions against so many consumptive patients coming daily were earning less than 92 a week, while 48 per cent. into their neighbourhood. This institution works partly for the received more than Z2a week, though apparently less than health authorities and partly for the Insurance Committee. 1:.160 a year. A wage limit would therefore restore to him If an insured person has phthisis and applies for sanatorium M private patients, paying full fees, 48 out of every 80 benefit he is referred to the physician in charge of the .nsured persons. Instead of a practice with only 20 per ’tuberculosis dispensary, and the latter advises as to the 3ent. of private patients and 80 per cent. of contract treatment which should be adopted ; in the majority of cases patients the wage limit would give him a practice this is domiciliary. When a patient returns from a sana- I)f 68 per cent. of private patients and only 32 per cent. ’torium he is expected to attend at the dispensary, and here I)f contract patients. After giving me these details my his progress will be watched and tuberculin treatment can nformant expressed the opinion that if the profession had be given. The Insurance Committee in these cases pays imade a firm stand in November, 1912, the wage limit could ’7. to the town, and the latter pays the physician who Ilave been introduced into the Bill. In Newcastle the attends at the tuberculosis dispensary. Then the town under- inedical profession has continued to feel keenly on this point, ’takes to provide 120 beds, but of these only 80 are actuallymd io was frequently mentioned to me. The Newcastle ’ready for patients. This tentative measure is probably[nsurance Committee, however, instead of deciding last Tight, for if a large hospital was built a prejudice mightfanuary whether they would establish a wage limit, put the arise against the place, and patients might refuse to go there, inatter off for three months. Then the committee would for there are no eompulsory,powers. However, there is one onelot at once discuss the matter, but wanted- the panel doctors
.drugs
I
t
1150 to sign the engagement first that they would continue they will have a smaller number of persons to attend. But their service for the remaining nine months of this year. in several places where this stand has been made doctors Thereupon four West-end doctors resigned, and after that, have come in from outside offering to do all that is required in the absence of those who were most interested in the for 6d. per fortnight. In the olden days, when the unions matter, it was easy for the committee to decide that were well organised and managed, the advent of such nothing could be done in regard to a wage limit. At a practitioners was promptly signalised, and they were so meeting of the Newcastle Trades Council the question of a rigorously dealt with that their departure was not long wage limit was also discussed, and one of the trade union delayed. But the merging of the local well-disciplined and representatives said "he would not think of consulting a fighting unions into the larger but not so compact British panel doctor." If there are many insured persons in New- Medical Association renders quick action less easy, and has castle who have not selected their panel doctor this is not discouraged many of the local practitioners who formerly due in the main to negligence, but to the fact that many fought so well. (To be continued.) members of the public do not care to be attended under the contract system. Thus they have, as it were, voluntarily imposed on themselves a wage limit, since they will pay fees and refuse che service of their panel doctor. Consequently WALES. the practitioners who have refused to go on the panel are OUR OWN CORRESPONDENT.) (FROM benefiting, particularly as they are not numerous. It will be seen, therefore, that in Newcastle medical men, consulting The Medieal Ogicerslbip of Health of Abertillery. merely their pockets, would not be unanimous in their views THE Local Government Board has constantly urged the of the Act. For some it has meant prosperity ; some have been hard hit by it. sanitary authorities in the Monmouthshire colliery districts to appoint whole-time medical officers of health, and in 1906 The Colliery Slw[Jeon8 and the 9d. definitely suggested the combination for that purpose of the urban districts of Abertillery, Nantyglo and Blaina, and there Neware two in the district Though only coalpits castle is nevertheless a great coal-trade centre, and it is from Ebbw Vale. The councils of these three districts were not Newcastle that the colliery surgeons were helped to organise able to come to any agreement on the matter, but about four their unions. It has been explained how these unions years ago the Abertillery council appointed, nominally as a succeeded in raising the pay from 6d. to 9d. per fortnight whole-time officer, Dr. A. E. Remmet Weaver, who was to per family, but this has been upset by the Insurance Act, hold the joint office of medical officer of health and and a new arrangement is still a matter of dispute. school medical officer, at a salary of 400 per annum. Now that those who work in the pits are insured persons Subsequently he was paid an additional E10 per annum the pitman as the head of a family refuses to pay the for acting as medical officer of the school clinic. Of 9d. per fortnight, since he is also paying for his own his total salary E250 were allocated as that of medical insurance separately and under the Act. A colliery surgeons’ officer of health, and one-half of this sum came committee does exist, but it is not easy to discover what it from the Exchequer grants, so that the contribution has done. The colliery surgeons, for the most part, have from the local rates to his salary was 285. In later been left to fight their own battle, and in their isolated, dis- years further grants were received from the Board of Educaorganised condition not a few have had to relapse into the tion, so that latterly the cost to the ratepayers has only been old terms of 6d. per fortnight for attending the non-insured E205 per annum. Dr. Weaver has been appointed medical members of a collier’s family. Undoubtedly, all the colliery officer of health for the borough of Yeovil, and the Abertillery surgeons should have been convoked so as to agree on the council is desirous of continuing to his successor the low terms they would one and all ask. Seeing that insured members salary which he has been receiving. The Local Government of each family contribute separately, it is quite natural that Board, however, is pressing for a minimum salary of S500 the colliers should expect to pay a little less for their families. per annum, which can hardly be considered extravagant for If the surgeons had unanimously offered to accept 8d. a district with a population of 39,000 persons scattered over instead of 9d. the probabilities are that this would have a hilly district with an area of ten square miles. There are A great number of colliery about 7000 school children, and the medical officer of health been generally accepted. surgeons, however, insisted on maintaining the 9d. Though is expected to attend at the fever hospital, to take charge of they would have fewer patients, they argued that the giving the school clinic, and to carry out the bacteriological of certificates would entail more trouble. Then there is examinations necessary. The avowed reason for paying so the question of the boys, on whom there is undoubtedly low a salary is that the local rates are so high. If economies a dead loss. Before the Act, when a boy reached the are to be exercised it is hardly prudent to do so by underage of 16 and descended into the pit to work, he paid paying a responsible official, the results of whose labours 6d. per fortnight for medical attendance, and in some dis- cannot always be measured in pounds, shillings, and pence. tricts he even paid the full 9d. per fortnight. At the lower The Red1wtion of Pauperism. figure this meant 13s. for the colliery surgeon. Now, and At the North Wales Poor-law Conference recently held in under the Act, the doctor only receives 7s. Under the Herbert Lewis, Parliamentary Secretary to the old system the fact that youths paid more than their share, Chester, Mr. Local Government Board, stated in his presidential address if judged by the amount of trouble they gave, served to comin Wales and Monmouthshire the rate of pauperism was that pensate the fact that the payments made for the women 25 per 1000 of the population, or a reduction of 5 per 1000 and children were insufficient. Also, before the Act if a the in past four years. In the whole of England and Wales certificate was required the colliery surgeon charged a the had been reduced in four years from 27 to 22 per rate shilling for it; now under the Act no charge can be made He suggested the desirability of appointing women for the certificates when required by insured persons. 1000. Thus a youth brings in 7s. per annum instead of 13s. as relieving officers. Pzcblio Health in the Rhondda Valleys. and has certificates for nothing instead of paying a The persistent attention that has been given in recent shilling for each. Then there is a new difficulty in regard to collecting the money from non-insured persons. years to the removal of insanitary conditions in the Rhondda When there was but one payment effected, and that urban district is at last bearing fruit, and the vital statistics was by the chief wage-earner, the colliery owner which the medical officer of health, Dr. J. D. Jenkins, deducted the amount from the wages and handed it includes in his recently issued annual report for 1912 This prevented bad debts and are of a very satisfactory character when compared with over to the colliery surgeon. But matters. to-day it is for the women and those of former years. The death-rate from all causes in that simplified children that the money has to be collected, and the colliery year was 13-8 per 1000, and the infantile mortality rate Also the money when was 127 per 1000 births. The latter rate was 26 per owners know nothing about them. collected has to be paid, not to one colliery surgeon, but to 1000 above that recorded during the same period in the different panel doctors. This the cashiers at the collieries 95 great towns of England and Wales, but it is the lowest object to do. It is not their business, and if they undertook Rhondda rate yet recorded. Among the most potent factors such work they would expect a commission of 5 to 10 per operating prejudicially to the preservation of infant life in cent. on the money handled. Thus it comes about that many the district, Dr. Jenkins mentions the abnormally high colliery surgeons insist on the 9d. as before the Act, though birth-rate, which in 1912 was 33’ 1 per 1000, the number of
Darjeeling and appointed to officiate as Civil year. With previous service he became Surgeon-Lieutenant Surgeon during the absence on sick leave of Major J. in 1893 and attained the rank of Major in 1905. He served Gwyther. Major H. B. Foster has taken up duty at in the South African war and took part in the operations in Calcutta. Major N. P. O’Gorman Lalor has arrived home on the Transvaal and in the Orange River Colony 1901-02 leave of absence from India. Major J. 0. Robertson has (Queen’s medal and two clasps). He was specialist in been appointed Sanitary Commissioner at Delhi. Major dermatology at Cairo in 1904, at Woolwich in 1905-06, and J. H. McDonald has been granted six months’ extension of at Malta in 1909. leave of absence home from India on medical certificate. Major L. J. M. Deas, Agency Surgeon to the Bhopawar State, has been appointed to officiate as Political Agent during the absence on leave of Lieutenant-Colonel B. E. M. Gurdon, C.I.E., D.S.O. Major V. H. Roberts, Civil Surgeon at Seoni, has been appointed to hold medical charge of the Chhindwara District during the absence of Captain W. J. Fraser on special duty at the Central Research Institute, Kasauli Cantonment. Major W. F. Harvey has taken up duty as Director of the Central Research Institute at Kasauli Cantonment in succession to Sir David Semple, R.A.M.C., who has relinquished the appointment. Captain N. M. Wilson, on return to India from leave of absence home, has been appointed to officiate as Civil Surgeon at Dera Ghazi Khan. Captain R. H. Bott has been appointed to officiate as Professor of Surgery at the Government Medical College, Lahore, during the absence on leave of Lieutenant-Colonel E. V. Hugo. Captain A. S. M. Peebles, superintendent of the Central Lunatic Asylum at Berhampore, has been appointed to officiate as Civil Surgeon of Murshidabad during the absence on deputation of Major C. A. Lane. The services of Captain R. S. Kennedy have been replaced at the disposal of the Government of India. Captain A. C. Ingram has been granted leave of absence home from India for one year and eight months. Captain M. J. Quirke has been appointed to officiate as Sanitary Commissioner to the Madras Presidency during the leave of absence of Captain M. A. Justice. Captain G. A. Jolly has been transferred fram Mainpuri and appointed Civil Surgeon at Fategarh. Captain H. S. Hutchison has been appointed to officiate as Deputy Sanitary Commissioner of the Central Registration District in Bombay during the absence on special duty of Lieutenant-Colonel T. E. Dyson. Captain J. H. Horton, D.S.O., has been appointed Civil Surgeon at Sukkur during the absence on leave of Major C. R. Bakhle.
SPECIAL RESERVE
OF
OFFICERS.
George F. Randall to be Captain (dated Sept. 19th, 1913). Lieutenant Charles J. Simpson resigns his commission (dated Oct. 15th, 1913). Lieutenant Henry P. Crow is confirmed in his rank. Lieutenant
TERRITORIAL FORCE.
Royal Army Medical Corps. lst Welsh Field Ambulance, Royal Army Medical Lieutenant Edmund V. Connellanto be Captain (dated
Corps : August
1st, 1913). 2nd Welsh Field Ambulance, Royal Army Medical Corps : Lieutenant John S. Rowlands resigns his commission (dated October llth, 1913). Attached to Units other than Medical Units.-Lieutenant Lewis Beesly to be Captain (dated June lst, 1913). Lieutenant-Colonel William Wilson resigns his commission, and is granted permission to retain his rank and to wear the prescribed uniform (dated October llth, 1913). For attaohment to Units other than Medical Units.Sidney Scott (late Second Lieutenant, 4th Northumbrian (County of Durham) (Howitzer) Brigade, Royal Field Artillery), to be Lieutenant (dated October llth, 1913). DEATHS
IN THE
SERVICES.
MEDICAL PRACTICE UNDER THE INSURANCE ACT. (BY
SPECIAL
COMMISSIONER.)
(Continued from p. 1024.) XXIII.—NEWCASTLE : EARLY ORGANISATION UNIONS AND THEIR DECAY.
OF
MEDICAL
AT Newcastle I found much dissatisfaction still prevalent to the manner in which the resistance to the National Insurance Act had been conducted, and in regard to the attempts to amend the Insurance Act the same feeling was expressed. It must be borne in mind that both in as
Northumberland and Durham the medical profession has been organised for some time, so that failure was not expected. Many strikes have taken place, and on the whole the medical unions in these contests came off victorious. Since the autumn of 1900 the work of organisation had been particularly active, and, indeed, I have described at length some of the achievements of the Northumberland and Newcastle Medical Association, and other bodies like the Newcastle Medical Ethical Society and the Northumberland and Durham Medical Union.I One of the chief of these achievements was the raising in most of the colliery districts of the sums paid to the colliery surgeons by no less than 50 per cent. Formerly the collier paid 6d. a fortnight for medical attendance on himself and his family, and this was raised to 9d. Then the war against imported medical men proved very effective, a black list was rigorously kept, and the cooperation of consultants was obtained. The different bodies, some of whom afterwards coalesced, were well disciplined fighting bodies, and their union was not merely a name but a reality, for they fought and won many a battle. To-day, however, what remains of these organisations has lost much of its old vigour with loss of individuality. This, perhaps, was inevitable. The British Medical Association, which under its new constitution absorbed these Northern medical leagues, was expected to strengthen the influence of the local unions, while it was said that expense would b& saved for those members who belonged to their local union It was aareedas well as to the British Medical Association. that the organisation of the unions should be maintained under the name of a committee, the Durham Committee and the Newcastle Committee of the British Medical Association. This amalgamation was effected some three years before theNational Insurance Bill was discussed, and did not work harmoniously. Nothing will be gained now by raking up old grievances ; it suffices to say that at one timethere were acute differences of opinion in Newcastle on the subject of united action in regard to the National Insurance Bill, but when the offer of 8s. 6d. was made public it was soon quite clear that resistance would no longer be possible. Professor Rutherford Morison and many others still think it would have been wiser to have accepted under protest this offer instead of exhibiting the weakness of the organisation of the profession by an abortive attempt at resistance. Nearly all the general practitioners went on the panel. The Insurance Oommi!tee’s Work. The population of Newcastle is 266,603, according to thelast Census, and the Insurance Committee has the record of 87,000 insured persons. There are 110 practitioners on the panel, though a few of them are not actually residing in Newcastle, but practise in the suburbs. The panel doctors were promptly paid on April 15th, the very day the money was due, the full Is. 9d. per person insured for their first quarter’s
Lieutenant-Colonel John Ritchie, R.A.M.C., on Oct. 6th Glasgow in his fifty-second year. He entered the service 1887, and in 1898 went out to West Africa. He was present at the operations in Sierra Leone, 1898-9 (medal with clasp), and during the South African war took part in the operations in the Orange River Free State in 1900, and later in the operations in the Transvaal, including the actions He was near Johannesburg, Pretoria, and Diamond Hill. also engaged in the operations in the Orange River Colony, including the actions at Wittebergen, and in Cape Colony, south of Orange River (Queen’s medal with four clasps and the King’s medal with two clasps). 1 See THE LANCET Major Herbert Cumming French, R.A.M.C., in his 44th 22nd, 1902. in in
OUR
of Feb. 23rd and April 6th, 1901, and Nov. 15th and
1149 work. The same business-like regularity occurred again on good feature already manifest in the attitude of the people -July lst, 1913. There remains a very large number, more at Newcastle. The idea of early treatment is becoming than 8000, of insured persons who have not yet selected a more and more popular. Also confidence has grown as to medical attendant. The money that these persons have the discretion observed at the dispensary. Nothing is ever .paid was divided equally among all the panel doctors. But said except in regard to children attending school, so that it is now proposed to allocate these insured persons, giving a adults coming for advice are not afraid of losing their larger number to the panel doctors who have the shortest employment. Thus persons who are in doubt now come ’lists. One panel doctor has about 3500 names on his freely to be examined at the tuberculosis dispensary, and list, and there are a few who have over 2000, but therefore it is all the more necessary that proper premises The great majority of panel doctors should be secured. this is exceptional. The are responsible for less than 2000 insured persons. Where the Wage Limit is Needed. .clerk of the Insurance Committee thinks that the Act In Newcastle the panel doctors working in the industrial is working well, and the fact that there has been no meeting of the medical subcommittee to sit and judge whether com- districts are well satifRed with results. In neighbourhoods plaints made as to medical attendance are well founded or such as Heaton they can get their visiting done with ease not is in itself evidence to the same effect. The dispensing and promptitude owing to the fact that the ceremonies of .chemists have been paid 85 per cent. on their claims. Their social calling are not required of them. But in the West-end bills have exceeded the Is. 6d., but when the floating 6d. is the position is different. Here we have a population of .added they have not overstepped the 2s. During the better clerks and persons of moderate incomes who are employed In the in trade or commerce. They live in small, well-kept, selfreason of the year the small deficit may be met. .meanwhile, it is very certain that more medicine has been contained houses, and many keep a servant. When the panel
.consumed than was ever the case before. If, therefore, are of real service, the inhabitants of Newcastle should now be in the enjoyment of better health than formerly. Of - course, some allowance must be made for the presence of malingering, of which complaint is made here as elsewhere. A scheme is being considered to create a medical committee whose business it should be to investigate suspected cases of malingering, and the proposal is that the panel doctors should sit in rotation on this committee, so as not to deal with their own cases. But, on the other hand, the objection .can be made that the detection of malingering is a specialty in itself, and every doctor is not equally competent. The fact recently announced that the Government is now attending to the matter has, however, checked to some extent local .efforts. Already two new committees are to be brought into existence in accordance with the recent amendments to the Act, one to represent exclusively the panel doctors and the other the dispensing chemists. As yet I have heard no complaints against this procedure. As long as the general Medical ’Committee representing all the members of the profession in the area remains intact, there seems to be no objection to the formation of minor committees to attend to special matter concerning individually the members of such committees and those who nominate them. However, these supplementary committees are not necessarily to be formed at once, so it is somewhat early to criticise.
doctor calls he cannot open the street door, announce himself, and walk straight in. He must ring the bell, wait perhaps while the servant girl puts on a clean apron before she opens the door. Then instead of seeing the patient at once he is introduced into a small parlour, where he lingers till the patient is apprised of the visit and has had his bedclothes straightened out a little. Altogether, the doctor finds that the visits to his contract patients absorb as much of his professional time as those to his private patients. This class of patient has been accustomed to pay the fees-low fees, of course-to their medical attendants; and the fact that to-day they are insured persons makes no difference to their domestic arrangements. Their front doors remain shut, and the doctor, whether on the panel or not, must ring the bell to gain admittance. Among the colliers living side by side in a row of little cottages, with their front doors open, it would be possible, though not desirable as a routine, to make 20, even 25, visits in an hour. At Newcastle, in such districts as Heaton, perhaps 15 visits may be made in the hour, but in the West-end three, four, Yet or five visits is the most that can be done in that time. in all these cases the remuneration under the contract system is exactly the same. So enormous is the difference and the loss it entails on the West-end practitioners that three of them have resigned their position on the panel. Here more than in any locality which I have yet visited has the necessity for establishing a wage limit seemed clearest to me. It is said, Inadequate Tuberculosis Dispensary;. however, that it is not worth while taking the great amount By far the most urgent matter at Newcastle at the present of trouble this would entail, for there are so very few insured moment is to obtain suitable premises for the tuberculosis persons whose income is above .6104 a year and under .6160. dispensary. This institution is for the moment situated close That is doubless true ; but if their number be small in comto the town hall. It is very accessible, but the street is so parison with a total of some 14,000,000 insured persons, noisy that it is difficult to examine the patients. Then the they cluster together, and in certain districts they dispensary only consists of two small rooms or compart- constitute perhaps the large majority of the inhabitants. One of these is the clerk’s room, the store-room, the Thus, if the medical profession as a whole does not suffer ments. writing-room, and the waiting-room, all in one. The other is much for the want of a wage limit its absence means grave the consulting-room, the bacteriological laboratory, and the loss for individual practitioners living in the districts where patients’ dressing-room, also all in one. An enormous this class of insured persons habitually resides. One practitioner in the West-end, who had about 1200 amount of time is lost by the medical officer, who has to wait till one patient has resumed his clothes before another insured persons on his list, told me that his private practice patient can be admitted into the room. But it appears that among people whose income exceeded Z160 amounted to when efforts have been made to rent larger and more 30 per cent. of the whole practice. The remaining 80 per suitable premises the people living near have raised objec- 3ent. were all insured persons, and of these only 32 per cent. tions against so many consumptive patients coming daily were earning less than 92 a week, while 48 per cent. into their neighbourhood. This institution works partly for the received more than Z2a week, though apparently less than health authorities and partly for the Insurance Committee. 1:.160 a year. A wage limit would therefore restore to him If an insured person has phthisis and applies for sanatorium M private patients, paying full fees, 48 out of every 80 benefit he is referred to the physician in charge of the .nsured persons. Instead of a practice with only 20 per ’tuberculosis dispensary, and the latter advises as to the 3ent. of private patients and 80 per cent. of contract treatment which should be adopted ; in the majority of cases patients the wage limit would give him a practice this is domiciliary. When a patient returns from a sana- I)f 68 per cent. of private patients and only 32 per cent. ’torium he is expected to attend at the dispensary, and here I)f contract patients. After giving me these details my his progress will be watched and tuberculin treatment can nformant expressed the opinion that if the profession had be given. The Insurance Committee in these cases pays imade a firm stand in November, 1912, the wage limit could ’7. to the town, and the latter pays the physician who Ilave been introduced into the Bill. In Newcastle the attends at the tuberculosis dispensary. Then the town under- inedical profession has continued to feel keenly on this point, ’takes to provide 120 beds, but of these only 80 are actuallymd io was frequently mentioned to me. The Newcastle ’ready for patients. This tentative measure is probably[nsurance Committee, however, instead of deciding last Tight, for if a large hospital was built a prejudice mightfanuary whether they would establish a wage limit, put the arise against the place, and patients might refuse to go there, inatter off for three months. Then the committee would for there are no eompulsory,powers. However, there is one onelot at once discuss the matter, but wanted- the panel doctors
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1150 to sign the engagement first that they would continue they will have a smaller number of persons to attend. But their service for the remaining nine months of this year. in several places where this stand has been made doctors Thereupon four West-end doctors resigned, and after that, have come in from outside offering to do all that is required in the absence of those who were most interested in the for 6d. per fortnight. In the olden days, when the unions matter, it was easy for the committee to decide that were well organised and managed, the advent of such nothing could be done in regard to a wage limit. At a practitioners was promptly signalised, and they were so meeting of the Newcastle Trades Council the question of a rigorously dealt with that their departure was not long wage limit was also discussed, and one of the trade union delayed. But the merging of the local well-disciplined and representatives said "he would not think of consulting a fighting unions into the larger but not so compact British panel doctor." If there are many insured persons in New- Medical Association renders quick action less easy, and has castle who have not selected their panel doctor this is not discouraged many of the local practitioners who formerly due in the main to negligence, but to the fact that many fought so well. (To be continued.) members of the public do not care to be attended under the contract system. Thus they have, as it were, voluntarily imposed on themselves a wage limit, since they will pay fees and refuse che service of their panel doctor. Consequently WALES. the practitioners who have refused to go on the panel are OUR OWN CORRESPONDENT.) (FROM benefiting, particularly as they are not numerous. It will be seen, therefore, that in Newcastle medical men, consulting The Medieal Ogicerslbip of Health of Abertillery. merely their pockets, would not be unanimous in their views THE Local Government Board has constantly urged the of the Act. For some it has meant prosperity ; some have been hard hit by it. sanitary authorities in the Monmouthshire colliery districts to appoint whole-time medical officers of health, and in 1906 The Colliery Slw[Jeon8 and the 9d. definitely suggested the combination for that purpose of the urban districts of Abertillery, Nantyglo and Blaina, and there Neware two in the district Though only coalpits castle is nevertheless a great coal-trade centre, and it is from Ebbw Vale. The councils of these three districts were not Newcastle that the colliery surgeons were helped to organise able to come to any agreement on the matter, but about four their unions. It has been explained how these unions years ago the Abertillery council appointed, nominally as a succeeded in raising the pay from 6d. to 9d. per fortnight whole-time officer, Dr. A. E. Remmet Weaver, who was to per family, but this has been upset by the Insurance Act, hold the joint office of medical officer of health and and a new arrangement is still a matter of dispute. school medical officer, at a salary of 400 per annum. Now that those who work in the pits are insured persons Subsequently he was paid an additional E10 per annum the pitman as the head of a family refuses to pay the for acting as medical officer of the school clinic. Of 9d. per fortnight, since he is also paying for his own his total salary E250 were allocated as that of medical insurance separately and under the Act. A colliery surgeons’ officer of health, and one-half of this sum came committee does exist, but it is not easy to discover what it from the Exchequer grants, so that the contribution has done. The colliery surgeons, for the most part, have from the local rates to his salary was 285. In later been left to fight their own battle, and in their isolated, dis- years further grants were received from the Board of Educaorganised condition not a few have had to relapse into the tion, so that latterly the cost to the ratepayers has only been old terms of 6d. per fortnight for attending the non-insured E205 per annum. Dr. Weaver has been appointed medical members of a collier’s family. Undoubtedly, all the colliery officer of health for the borough of Yeovil, and the Abertillery surgeons should have been convoked so as to agree on the council is desirous of continuing to his successor the low terms they would one and all ask. Seeing that insured members salary which he has been receiving. The Local Government of each family contribute separately, it is quite natural that Board, however, is pressing for a minimum salary of S500 the colliers should expect to pay a little less for their families. per annum, which can hardly be considered extravagant for If the surgeons had unanimously offered to accept 8d. a district with a population of 39,000 persons scattered over instead of 9d. the probabilities are that this would have a hilly district with an area of ten square miles. There are A great number of colliery about 7000 school children, and the medical officer of health been generally accepted. surgeons, however, insisted on maintaining the 9d. Though is expected to attend at the fever hospital, to take charge of they would have fewer patients, they argued that the giving the school clinic, and to carry out the bacteriological of certificates would entail more trouble. Then there is examinations necessary. The avowed reason for paying so the question of the boys, on whom there is undoubtedly low a salary is that the local rates are so high. If economies a dead loss. Before the Act, when a boy reached the are to be exercised it is hardly prudent to do so by underage of 16 and descended into the pit to work, he paid paying a responsible official, the results of whose labours 6d. per fortnight for medical attendance, and in some dis- cannot always be measured in pounds, shillings, and pence. tricts he even paid the full 9d. per fortnight. At the lower The Red1wtion of Pauperism. figure this meant 13s. for the colliery surgeon. Now, and At the North Wales Poor-law Conference recently held in under the Act, the doctor only receives 7s. Under the Herbert Lewis, Parliamentary Secretary to the old system the fact that youths paid more than their share, Chester, Mr. Local Government Board, stated in his presidential address if judged by the amount of trouble they gave, served to comin Wales and Monmouthshire the rate of pauperism was that pensate the fact that the payments made for the women 25 per 1000 of the population, or a reduction of 5 per 1000 and children were insufficient. Also, before the Act if a the in past four years. In the whole of England and Wales certificate was required the colliery surgeon charged a the had been reduced in four years from 27 to 22 per rate shilling for it; now under the Act no charge can be made He suggested the desirability of appointing women for the certificates when required by insured persons. 1000. Thus a youth brings in 7s. per annum instead of 13s. as relieving officers. Pzcblio Health in the Rhondda Valleys. and has certificates for nothing instead of paying a The persistent attention that has been given in recent shilling for each. Then there is a new difficulty in regard to collecting the money from non-insured persons. years to the removal of insanitary conditions in the Rhondda When there was but one payment effected, and that urban district is at last bearing fruit, and the vital statistics was by the chief wage-earner, the colliery owner which the medical officer of health, Dr. J. D. Jenkins, deducted the amount from the wages and handed it includes in his recently issued annual report for 1912 This prevented bad debts and are of a very satisfactory character when compared with over to the colliery surgeon. But matters. to-day it is for the women and those of former years. The death-rate from all causes in that simplified children that the money has to be collected, and the colliery year was 13-8 per 1000, and the infantile mortality rate Also the money when was 127 per 1000 births. The latter rate was 26 per owners know nothing about them. collected has to be paid, not to one colliery surgeon, but to 1000 above that recorded during the same period in the different panel doctors. This the cashiers at the collieries 95 great towns of England and Wales, but it is the lowest object to do. It is not their business, and if they undertook Rhondda rate yet recorded. Among the most potent factors such work they would expect a commission of 5 to 10 per operating prejudicially to the preservation of infant life in cent. on the money handled. Thus it comes about that many the district, Dr. Jenkins mentions the abnormally high colliery surgeons insist on the 9d. as before the Act, though birth-rate, which in 1912 was 33’ 1 per 1000, the number of